Health History - Adults

Health History Form & Lifestyle Questionnaire

PATIENT INFORMATION

Patient Name

Today’s Date

Gender

Preferred Pronoun:

Last Eye Doctor/Location

Date of last eye exam

Primary Care Physician/Location:

Date of last physical exam

Occupation

What is the main reason for your visit today?

Do you have any other visual/ocular problems?

SPECTACLE/CONTACT LENSES

Do you primarily wear glasses?

How old are your current glasses?

Do you wear contact lenses?

Are you interested in a new contact lens design?

Are you interested in refractive surgery (laser or cataract) options?

COMPUTER USE

How many total hours per day do you use a computer, cell phone, tablet or play video games?

Do you use computer glasses?

Are you interested in special glasses to make computer work easier?

SPORTS & LEISURETS ACKNOWLEDGEMENT

What sports/hobbies do you participate in?

Do you wear any special eyewear for your sport/hobby?

Do you currently wear sunglasses?

Are you sensitive to bright lights?

DRY EYE QUESTIONNAIRE

Please check off the following for SEVERITY and FREQUENCY of dry eye symptoms:

Severity of Symptoms

Legend

0 - No problems
1 - Tolerable (not perfect, but not uncomfortable)
2 - Uncomfortable (irritating, but does not interfere with my day)
3 - Bothersome (irritating and interferes with my day)
4 - Intolerable (unable to perform my daily tasks)

Dryness, grittiness or scratchiness

Soreness or irritation

Burning or watering

Eye Fatigue

Frequency of Symptoms

Legend
0 - Never
1 - Sometimes
2 - Often
3 - Constant

Dryness, grittiness or scratchiness

Soreness or irritation

Burning or watering

Eye Fatigue

Review of Systems

Please check the boxes that apply. Unchecked boxes will mean “no”.

Allergy

Constitutional

Cardiovascular

Endocrine

Gastrointestinal

Genitourinary

Head

Hematologic/ Lymphatic

Immunologic/ Integumentary (Skin)

Musculoskeleta

Neurologic

Psychiatric

Respiratory

Eye History

Conditions

Surgeries

Medical History

Family History

Ocular

Medical

Social History

Medications*

Name

Dose

Purpose

*Please include over the counter medications, eye drops, vitamins, contraceptives, and herbal supplements.

I verify that the information contained on this page is current.

Patient Signature

Date

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